Veterinary medical record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for vets to spend time thinking and talking about. However, it’s incredibly important, and Guild’s claims management experience suggests vets would benefit from learning more about good record keeping.
Records and insurance claims
Records can impact insurance claims in two ways:
- Poor records can contribute to a poor or unexpected outcome following treatment, leading to the client complaining and possibly seeking some form of compensation. For example, if an animal’s weight is accidentally recorded incorrectly, this could lead to medication errors.
- Inaccurate or incomplete records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence of what took place and why.
Poor clinical outcomes and dealing with complaints can be very challenging and confronting. Therefore, understanding how to improve the standard of records really should be a focus.
Why keep detailed records?
1. Continuity of care
It’s not uncommon for vets to think they’ll remember the details of their consultations. However, at Guild we see cases where key information hasn’t been remembered, and this has led to a poor outcome. It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated an animal in the past.
It’s also important to be sure you refer to the information within the record. Animals can suffer harm when key information is overlooked or forgotten about and they’re therefore not treated accordingly.
2. Regulatory requirement
All State and Territory Veterinary Boards within Australia have a guideline or policy about obligations and requirements regarding record keeping.
It’s the responsibility of every vet to make themselves aware of, and comply with, the various codes, guidelines and policies relevant to them. Not knowing is not an excuse for not complying.
3. Defence of a complaint
If there’s an allegation of wrong doing, the records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the vet will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a vet’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.
What to record?
A question many ask when it comes to record keeping is, ‘How much detail do I need to record?’ Vets should refer to their relevant Veterinary Board’s information to better understand the detail required in a record.
Exactly what to include can vary according to the specifics of the animal’s condition and treatment. However, generally records should include, but aren’t limited to:
- client identification
- treatment date
- animal(s) identification
- history
- examination details
- diagnosis
- treatment options offered and given, prescribed, or supplied
- informed consent
- response to treatment
- other records/reports such as imaging reports, laboratory reports or specialist/referral reports
- information provided to the client including post treatment instructions
In some cases, it’s worth noting what didn’t occur as well as what did. For example, if a client has refused to consent to what would be considered the most ideal or obvious treatment option, the record should reflect that it was discussed and declined. If it’s simply left out of the record, it would appear that it wasn’t discussed as an option.
When vets are unsure if they’ve included enough detail, they should ask themselves whether or not another vet could read the record and understand the full picture of what took place and why. If the full story isn’t there, there isn’t enough detail.
Professional and objective
Records need to always be professional and objective. Negative comments about the client can be included, however this must be professional and only when relevant to the treatment being provided. This may occur in situations where the client isn’t complying with instructions and this is detrimental to the health of their animal. However, it’s important to remember that records can be accessed and read by a number of people, including the client and your regulator, so always be mindful of the language used. The language should match the professional language used when speaking to the client during a consultation.
Changes and corrections
If it’s noticed that errors have been made in a record, changes can be made to correct this. However, information should never be deleted. The original information must remain with a note explaining the correction and when the correction was made. Also, if additional information needs to be added to a completed consultation note, it should be done so it’s clear this is additional information, with the date it was added.
Artificial intelligence
As with many other parts of our lives, the use of artificial intelligence (AI) is creeping into record keeping practices. While there are numerous potential benefits of using AI, there are also risks that vets need to understand and manage. The first step requires thoroughly researching any AI tools they intend to use and being sure of how they work, particularly in relation to the storage and use of information inputted into them.
The task of creating appropriate records can’t be left to AI; vets must review any AI-generated information to be sure it’s detailed and accurate. And when doing this, they must keep in mind that AI isn’t perfect; it will at times leave out important information and even make things up. It’s also important to be sure clients are aware of the use of AI. When client data is being inputted into an AI tool, or if consultations and discussions are being recorded, informed consent is a must.
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